Ethical issues

Associated with increasing longevity, death and dying

1. Based on: Ageing: The New Ethical Frontier 
Reference: Patrick McArdle (2012) Ageing: The New Ethical Frontier, Journal of Religion, Spirituality & Aging, 24:1-2, 20-29, DOI: 10.1080/15528030.2012.633042

New ethical considerations occur with increasing longevity. What is the right thing to do, for example, when an 80-year-old man in good health needs an organ transplantation? How should limited resources be allocated between young and old people?

Before the second world war, it was implicitly assumed that doctors had the training and wisdom to do what was ethically correct in all situations related to health. But the actions of certain physicians during the war when they sided with the combatants, and the reports of their participation in ethically questionable experiments like the Tuskagee Syphilis Study, have challenged this assumption.

Ethical decisions in medical practice have always been focused on patient autonomy and doing what the mentally-competent patient desires. Such decisions are not very difficult to make when the patient is young or is not entirely dependent on caregivers. What is the right thing to do when a 72-year-old man with prostate cancer, multiple bone metastases, develops pneumonia and a fracture of a bone? Is hospice and palliative care the right thing to consider or should doctors treat the pneumonia and the fracture as they would for a patient who does not have advanced cancer? What if the patient says he wants to get well and back on his feet while his caregivers are already stretched to their physical and emotional limits and would prefer that the man's suffering is not needlessly prolonged? This kind of scenario illustrates the new kinds of ethical dilemmas for people as they grow older and older because the ability and willingness of those who care for the patient must be considered in decision making. It is also interesting to consider the state of mind (mental competence) of this elderly patient with advanced metastatic cancer, who unrealistically desires to be treated so that "he gets back on his feet",

Ethical dilemmas in this new frontier of ageing will increasingly involve relationship and financial issues. When older people develop new physical and sexual relationships with each other, these can disapproved by their children and caregivers. Doctors will have to struggle to decide whether such actions (disapproved by others) should be attributed to mental illness or not. One way to make right ethical decisions is to consider the web of relationships in which the patient is placed. Instead of only determining what is in the patient's best interest in terms of individual needs, it may be necessary in the case of older adults to also determine what is in the patient's best interest in terms of the patient's web of relationships. This is necessary because, as we grow older, it is the relationships that we have with others that determines the quality of our self-satisfaction.

2. Based on: Mortality and Morality: Ageing and the Ethics of Care (Reference)

The trajectory of dying in old age is viewed and experienced differently in different societies and in different economic strata. There is ambiguity over when the process of growing older shifts into the process of dying, We assume that older people know how to die but this assumption is often incorrect because many people do not know when to start "letting go" which is what the process of dying requires. Individual autonomy is the ethical principle most often followed in medical practice but at the end of life, an exclusive emphasis on this can prevent a smooth process of dying because at the end of life, if social contexts and relationships are ignored, a good death may not be possible.

A good death occurs when the procedures and practices at the end of life do not block and distort the trajectory of dying. We need to display as much attention and sensitivity to the process of dying as we do to the process of birth. A very important aspect of a good death is that dying should happen in surroundings that are comforting to the dying person. The principles of palliative care should increasingly be applied to those who are in the hours, days or weeks of the process of dying. A prolonged period of deterioration and decline in physical and mental abilities often occurs before death and how this period is handled will determine how death is experienced. Awareness of the dying condition, ability to choose the nature of treatment include the ability not to have life prolonged, time to say goodbye and access to emotional and spiritual support are also important components that lead to a good death.

At the time of dying there may be many needs to be met. Ethical dilemmas will arise over the question: Which are the needs that can be met with the available resources? Ultimately someone like an amicus mortis will be needed - a person who will make decisions and take care to see that dying is not more painful than necessary. And the healthcare profession, which often battles to prevent death and prolong life, must also learn to recognise when the time has come to make the process of dying as easy and comfortable as possible

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